The Effect of Metabolic Persian Diet on Ovulation Induction in Infertile Women

Introduction Infertility is an important issue with a high social and psychological burden. From the perspective of Persian Medicine (PM), uterine cold temperament is one of the important causes of female infertility. Aim The aim of this study was to study the effect of PM or Iranian traditional medicine on improving ovulation and fertility. Methods From January 2017 to August 2017, sixty infertile women with eugonadotropic ovulation disorder were randomly divided into two groups. Both groups were treated with clomiphene citrate, except that the intervention group also received metabolic Persian diet (MPD). In each cycle, the dominant follicles and endometrium were investigated with ultrasound. At the end of the cycle, beta human chorionic gonadotropin (β-HCG) was evaluated and if positive, another ultrasound was performed two weeks later to confirm early pregnancy. Results The number of dominant follicles from the first to third cycle increased from 2.15 ± 1.14 to 2.28 ± 0.61 in the intervention group and decreased from 1.86 ± 0.79 to 1.30 ± 0.47 in the control group. The dominant follicle size changed from 16.00 ± 4.08 to 18.78 ± 2.78 and from 15.05 ± 3.11 to 15.80 ± 3.89 in the intervention and control groups, respectively. But endometrial thickness did not change significantly in the intervention group. Pregnancy results based on β-HCG and ultrasound findings were positive in 19 and 16 patients in the intervention group and in 10 and 7 patients in the control group, implying significantly higher numbers in the first group. Conclusion It seems that MPD may be effective in the success of ovulation induction.


Introduction
Infertility, as one of the relatively common and serious problems among couples, is characterized by the absence of pregnancy after 12 months of unprotected intercourse [1,2].
According to several studies, this problem is prevalent among about 15% of couples worldwide [3,4]. Ovulatory disorders are one of the most common causes of infertility in women, and polycystic ovary syndrome (PCOS) has the largest share of these disorders [5]. Te results of a study in Iran revealed that these disorders were involved in 57.7% of infertility among women, while PCOS alone in about 66% of cases was the underlying cause of ovulation problems [6].
Higher rates of psychiatric disorders and endometrial cancers in infertile women along with an increased risk of cardiovascular disease and metabolic disorders in women with PCOS, as reported in several studies, should be given more attention. In addition to these problems, the high cost of treatment is a major concern for infertile couples and a considerable burden on health system [7].
According to the World Health Organization, ovulatory disorders are divided into three categories. In the normogonadotrophic group (or group II disorders) accounting for about 85% of patients, PCOS is the major underlying cause. However, in this category, obesity and hormonal disorders, such as hyperprolactinemia or hypothyroidism, also cause infertility in a smaller percentage of women [8]. Hence, ovulation induction is the logical treatment for infertility of these patients. In addition to good efectiveness and better safety, it is a noninvasive and cheaper method than the in vitro method or IVF [9][10][11]. Nevertheless, despite the benefts of ovulation induction, according to several studies, the success rate of this method in fertilizing women is less than 20% [12]. In addition, IVF, despite the high costs, results in pregnancy and live birth in 37.3% and 29.6%, respectively [13,14].
On the other hand, today, the importance of nutrition in infertility is somewhat known [15]. Te association between preconception diet and the chance of pregnancy in women undergoing IVF/ICSI treatment was reported in a study. Te results showed that improving nutritional status, according to Dutch dietary recommendation, increased fertility outcomes in patients [16]. Two other studies found the diet modifcations as an efective factor and suggested that more adherences to the Mediterranean diet may help increase the chances of conceiving better outcomes for women undergoing IVF treatment [17]. In addition, numerous studies have examined the efect of diet on ovulatory disorders. One example would be the prospective study of more than 17,000 women over eight years, which found that high adherence to "fertility diet" (comprising increased intake of unsaturated fats and plant proteins) reduces the risk of infertility associated with ovulatory disorders in the future [18]. Also, a recent randomized clinical trial showed that a diet and lifestyle modifcation based on Persian medicine (PM) signifcantly increased the success of treatment in the women undergoing assisted reproduction [19].
PM is a valuable collection with long history of experience of Iranian physicians, being used in the feld of prevention and treatment of various diseases [20]. Avicenna and Rhazes are among the most PM scholars infuencing medical science for centuries, not only in Iran and Middle Eastern countries but also in Europe and the West [19,21]. Increasing the quality of life in healthy people (21) and reducing the cost of diseases [22] are the major priorities in PM. Some interesting results of the studies inspired by the opinion of ancient scholars indicate that PM in the feld of gynecology also has the ability to provide efective treatments [23,24].
In general, from the perspective of PM, the frst and most important step in the treatment of diseases is lifestyle modifcation, in which nutrition is of particular importance [25,26]. According to PM scholars' point of view, foods are divided into two categories of hot and cold, while each of them afects the physiology of various body organs based on its temperament. Recent research has also confrmed the idea that the hormonal, autonomic, immune, and digestive systems each respond diferently to hot and cold foods [25]. Moreover, according to PM, people are divided into two general groups of hot-and cold-tempered, whose immune and endocrine systems are signifcantly diferent and their diet should be adjusted based on their temperaments [27][28][29]. In modern medicine, there is a similar view called "personal medicine" and it pays attention to the wide individual diferences in the prevention and treatment of diseases [30].
So, considering the temperamental view of PM about diseases and the fact that most types of infertility fall into the category of cold diseases, the frst step of treatment would be to utilize a therapeutic diet that inclines the body and ovary temperament to heat [31]. To achieve this goal, metabolic Persian diet (MPD) is designed according to the constitutional perspective of PM, for this category of diseases that temporarily eliminates cold-tempered foods from the consumption of patients. In this diet, despite the elimination of cold-tempered foods, the view of modern knowledge of nutrition has also been completely considered, by providing all categories of food pyramid [32].
Given the importance of infertility and high costs, an attempt was made to investigate the efect of MPD as a simple, inexpensive, and uncomplicated method on the success of ovulation induction.

Materials and Methods
Te current study was a quasi-experimental clinical trial (intervention and control group) performed on patients referred to an academic infertility center of Akbarabadi Hospital in Tehran, Iran, from January 2017 to August 2017. Herein, the objectives of the study, being in full compliance with the Helsinki Declaration, were explained to the patients and their written consent was obtained.

Participants.
Eligible participants in this study were women aged 20-35 years with ovulation-related infertility, who have experienced less than three courses of ovulation induction.

Inclusion Criteria.
Tose who volunteered to participate in the study and flled out the consent form, who do not have any chronic physical disease, who do not have history of mental health problems, and have ovarian-associated infertility and serum FSH (follicle-stimulating hormone) levels between 1 and 15 IU/L were included in the study.

Exclusion Criteria.
Participants who interrupt the diet for more than 24 consecutive hours or do not perform ultrasound and paraclinical evaluations will be excluded from the study.

Study
Design. In the current work, the continuous sampling method was performed on two diferent days. On the frst day of attending the infertility center, through the lottery method, it was determined that the samples were included in the intervention group and the next day in the control group until the end of the sampling stage; hence, preventing the control group from receiving the diet.
To determine the required sample size at 95% and a power of 80%, and to evaluate the efect of MPD on the follicle growth in women undergoing ovulation induction, if the efect of dietary intervention on the follicle growth compared to the control group is equal to 2.5 (d � 2.5) to make this intervention statistically signifcant, after quantifcation in the following formula, the required sample volume was estimated to be 60.
Sample size in each group was estimated to be N � 23. Assuming a sample drop of 10%, the required sample volume was estimated to be N � 30. In addition, based on part of our pilot study conducted on 12 patients, the standard deviation of follicle growth in the control and intervention groups was estimated to be 4.5 and 1, respectively.
Te information of participants was obtained through interviews and the data in medical records. A researchermade demographic questionnaire included 25 questions about the couple's age, education level, and occupation along with the patient's fertility characteristics, including the number of pregnancies, deliveries, and abortions, history of infertility, method and the duration of contraception, menstrual characteristics, the rate of sexual intercourse, and anthropometric indices. Tis information was obtained in order to investigate the real efect of the intervention on fertility via matching study groups.
In addition to the initial nutritional assessment at the beginning of the study using the 24-hour dietary recall questionnaire, to check adherence with diet, this questionnaire was completed twice more by patients: in the middle of the study (six weeks following the intervention) and at the end of the third cycle. However, for women who became pregnant before six or 12 weeks, 24-hour dietary recall was not checked in the second and third rounds, respectively. It should be noted that 80% adherence to the diet was accepted. Te data related to the 24-hour dietary recall questionnaire were investigated by a nutritionist with food processor software and N4, and the information about the diet plan was obtained.

Intervention.
In the present study, all patients were evaluated for three menstrual cycles. In the frst cycle, in order to induce the ovulation, patients of both groups took 100 mg of clomiphene citrate daily from day three to seven of menstruation. If pregnancy did not occur in each cycle, the dose of clomiphene citrate was repeated in the second and third cycles.
Te necessary instructions in the MPD were explained to the patients in the intervention group. Te training was provided in the form of face-to-face and pamphlet training. Patients had to follow this diet as soon as the treatment with clomiphene citrate started in the frst cycle. Patients in the intervention group had to follow this diet until the end of the third cycle or until pregnancy was confrmed before the end of the third cycle. In contrast, the control group did not receive any instructions and were monitored for three cycles. Te diet plan provided to patients is described in Table 1.

Outcome Measure.
Te frst main outcome of the study was related to ovarian and uterine fndings and the second one was related to fertility. Te frst one included the number of dominant follicle, dominant follicle size, and endometrial diameter. Tese parameters were assessed via ultrasonography ultrasound on day 14 of the menstrual cycle. If the dominant follicle size was between 18 and 20 mm in ultrasonography, injectable human chorionic gonadotropin (HCG) at a dose of 5,000 units was prescribed by an infertility fellowship. Te ultrasonography of all patients was performed by the same person in one place (Hounds electric HS2100 ultrasonography device, made in Japan, 2013).
Fertility outcome was performed in two ways: laboratory test and ultrasonographic examination. In this method, the β-HCG test was performed between days 28 and 30 of menstruation. To measure serum β-HCG, an enzyme-linked immunosorbent assay (ELISA) reader with awareness stat fax 3200 model was employed. In β-HCG-positive individuals, ultrasonography was performed again at weeks six to seventh, the results, including the type of pregnancy in terms of implantation location and fetal heart rate, were recorded in the data sheet. On the other hand, in β-HCGnegative patients the mentioned diagnostic protocol was repeated in the second and third cycles.

Statistical
Analysis. Data were analyzed applying Statistical Package for Social Sciences (SPSS) software version 21. Signifcance level was considered less than 0.05. After entering the information into the software, the data were Evidence-Based Complementary and Alternative Medicine

Patients.
All sixty patients completed the study and second and third round evaluations with 24-hour food recall questionnaire showed that adherence to MPD for all patients in the intervention group was within the desired level above 80%. Te expected follow-up was also performed by all patients (Figure 1). Te demographic characteristics of the study groups are represented in Table 2. Tere was no signifcant diference between the two groups in terms of age of husband, BMI, number of marriages, duration of marriage, education level of patient and husband, employment status of patient and husband, and their economic status.
Moreover, the surveys on the fertility characteristics of the studied women indicated that there was no signifcant diference between the two groups. Tese characteristics are expressed in Table 3. Table 4, considering the size and number of dominant follicles in the frst and second cycles, there was no signifcant diference between the study groups after the start of the intervention; yet, in the third cycle, the ultrasonographic parameters in women receiving the MPD were signifcantly higher than the control group (P value <0.001 and P value � 0.019). However, the results obtained from the endometrial diameter did not reveal any signifcant diferences in any of the three cycles following the intervention.

Main Findings. As shown in
Nevertheless, regarding the most important parameters of this study, namely, pregnancy, laboratory results of β-HCG and ultrasonography implied that in the intervention group, the rate of pregnancy was signifcantly (30%) higher than that in the control group.

Discussion
In the current study, in order to investigate the real efect of MPD on the success rate of ovulation induction, study groups were matched in terms of demographic, social, and reproductive parameters. Te results implied that MPD is signifcantly efective in fertility in women with ovulation disorders. Tis diet has increased the chances of pregnancy in infertile women by 30%. Tese results prove the opinion of Persian physicians declaring that the constitutionally warm diet has a positive efect on cold-tempered diseases such, as female infertility.
Our previous study showed the efectiveness of a special diet in improving the symptoms of functional dyspepsia.
Due to PM perspective considering indigestion as a chronic disease caused by cold and wet temperament of the stomach, foods that require a lot of energy for digestion and are considered extremely cold, wet, heavy, and harmful to the stomach in the mentioned viewpoint were excluded from patients' diet. Te results showed that in the group receiving the metabolic Persian diet (MPD), indigestion, loss of appetite, epigastric night pain, and epigastric irritation were signifcantly improved compared to the beginning of the trial. Te reduction of a wide range of symptoms following this diet is a signifcant fnding because common treatments such as PPI and prokinetics only improve some of the symptoms [33].
Also, another recent clinical study showed the efectiveness of a traditional medicine-based lifestyle and diet on infertility treatment in women undergoing assisted reproduction. Te diet that was used in the mentioned study was also designed based on warm-tempered foods and adjusted according to the temperament of each patient [34].
Indeed, other studies have addressed the importance of nutrition and diet in female infertility. For instance, in the study of Twigt et al., the efect of nutrition on the success of IVF/ICSI treatment has also been highlighted. Teir results indicated that for each increase in Preconception Dietary Risk (PDR) score, an indicator for measuring the quality of nutrition, the incidence of pregnancy with assisted reproductive techniques was increased by 65% [16].
A prospective study of more than 18,000 women of childbearing age also found that women consuming the most low-fat dairy had a 1.85-fold higher chance of an ovulatory infertility than women consuming the least [35].
In a recent trial, like this study, examining a MPD along with teaching healthy eating habits, the results showed pregnancy rate after 3 months in the intervention and control groups were 35.2% and 12.4%, respectively, in infertile women under IVF. Also, the number of ovum number and mature ovum number increased signifcantly under the infuence of these trainings. However, unlike the present study, it does not ofer a therapeutic diet for the cold temperament, but examines a healthy diet that recommends relatively hot-or cold-tempered foods that produce healthy humors in the body [34].
In PM, to manage the disease, food should be evaluated from two aspects: quantity and quality. In terms of quantity, fasting and calorie restriction are among the therapeutic strategies applied in certain conditions [16]. However, once the temperament of the body or an organ, such as the ovary is out of balance and tends to hotness or coldness, the quality of the foods is also taken into consideration. In this case, the use of foods or in the second step, drugs with the opposite temperament can restore the body's homeostasis.
So far, few studies have examined the concept of temperament, one of these which showed some diferences in neuroendocrine in people with diferent temperaments. Te sympathetic nervous system is signifcantly more active in hot-tempered people, whereas the parasympathetic nervous system, sympathoadrenal system, and corticosteroid secretion are more active in cold-tempered people [27].  An animal study revealed that hot-tempered food signifcantly increased thyroid hormones and urine vanillylmandelic acid (VMA). On the contrary, adding coldtempered seeds to the rats' diet increased serum cortisol and decreased the VMA levels. Changes in urinary VMA levels indicated an increased activity of the sympathetic nervous system following the consumption of hot-tempered grains and vice versa [36].

Evidence-Based Complementary and Alternative Medicine
Te efect of hot foods on thyroid function is when this hormone plays an important role in female fertility. According to several reports, up to 11.3% of infertilityrelated disorders present with subclinical hypothyroidism  Evidence-Based Complementary and Alternative Medicine [8]. Sex hormones are no exception to this rule and are afected by food and diet. Several studies have linked the increased dairy consumption to the change in female sex hormones. One study performed on 259 women with regular menstruation showed that the increased dairy consumption was associated with decreased serum estradiol. It was also revealed that consuming cream and yogurt raises the risk of sporadic anovulation [37]. Tis is while in MPD, most dairy foods with a cold temperament from the perspective of PM, such as yogurt, yogurt drink, and cream, are temporarily banned. However, the mechanism of the positive efect of MPD on the success of ovulation induction is not exactly clear. Tis requires further studies in the future. It is also recommended that the efect of this diet on other causes of infertility, including male and female causes be evaluated. Moreover, studying the efect of MPD on IVF success can be helpful in demonstrating the efect of this lifestyle-related treatment on infertility. Using modern analytical techniques to determine the chemical characteristics of the MPD can be the subject of further studies to standardize this diet.

Conclusion
Te results of this study indicated that the use of MPD (by eliminating cold-tempered foods) may improve the success of ovulation induction in infertile women. It seems that this simple and uncomplicated diet could be considered to be a part of infertility treatment.

Data Availability
Te data that support the fndings of this study are available upon request from the corresponding author, L. Neisani Samani.

Ethical Approval
Permission and introduction letter were obtained from the Ethics Committee of Iran University of Medical Sciences and the approval of the ethics committee is under the number IR.IUMS.REC.1395.9311373009.

Consent
Informed consent was obtained from the participants.

Conflicts of Interest
Te authors declare that they have no conficts of interest.